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4/11/2007 Survey Tag 0196 Detail for:
FRESENIUS MEDICAL CARE DENVER CENTRAL DIALYSIS
Wednesday, October 23, 2019 12:20 AM

Survey Date: 4/11/2007

Regulation Number:0196

Regulation Title: PATIENT CARE PLAN: FREQUENCY

Regulation Description: The care plan for patients whose medical condition has not become stabilized is reviewed at least monthly by the professional patient care team described in 405.2137(b)(2) of this section. For patients whose condition has become stabilized, the care plan is reviewed every 6 months. The care plan is revised as necessary to ensure that it provides for the patients' ongoing needs.

Surveyor Findings:


Based on medical record review, staff interview and policy manual review, the facility failed to ensure that:
1. Care plans were completed as necessary to ensure it provided for the patients ongoing needs in two (#1 and #4) of 11 sample patients and
2. A care plan for a patient whose medical condition had not become stabilized was reviewed at least monthly in one (#6) of 11 sample patients.

The failure to ensure patient care planning was conducted as necessary created the potential for inadequate and/or inappropriate provision of care. The findings were:

The facility's policy and procedure entitled "Hemodialysis Short-Term Care Plan," policy #17-PP-1.02 dated 6/7/05, was reviewed on 4/10/07. The policy reads in pertinent part; "The STCP (Short Term Care Plan) will be developed within 30 days of admission to the outpatient facility, will be updated every 6 months thereafter for stable patients, monthly for unstable patients..."

The medical record for sample #1 was reviewed on 4/10/07. The STCP dated 11/28/06 was signed by all disciplines as having been completed. However, it was only partially completed by the registered nurse. The STCP dated 1/4/07 was completed by the dietitian and the social worker but the registered nurse did not complete any portion of it.

The medical record for sample #4 was reviewed on 4/10/07. The STCP dated 1/3/06 was signed by all disciplines as having been completed. However, it was not completed by the social worker or the registered nurse.

The medical record for sample #6 was reviewed on 4/10/07. The STCPs from 11/06 through 3/07 documented the patient as being unstable and a review care plan should be done monthly. However, a STCP for 2/07 failed to be implemented.

The clinical manager was interviewed on 4/10/07 at 3:45 p.m. regarding the incomplete STCPs. The manager stated chart audits are performed on a quarterly basis, but did not know how the audit had missed the incomplete STCPs or the monthly STCP for the unstable patient.

Facility Plan of Correction:

V000
The Governing Body of this facility – whose membership includes the Medical Director, the Clinical Manager, and the Area Administrator - takes seriously its responsibilities regarding the development, implementation and monitoring of policies and procedures for the day-to-day operations and governance of the facility to ensure the health and safety of patients and staff. As such, the Governing Body initially met on 04/23/07 at 11:00 AM
to review and discuss the forthcoming Statement of Deficiencies and to develop the following Plan of Correction.

The Governing Body, at that same meeting, determined to meet at least every month, from the date of the meeting through June 30th 2007, to hear reports from staff designated as responsible for each corrective action and thus, to monitor progress, implementation and maintenance of corrective actions. Minutes of the referenced, and all subsequent GB meetings documenting this activity are available for review at the facility.


405.2137(b)
V 196
Care plans have been completed for the identified patients in the SOD.

The Clinic Manager will in-service the staff on the policies related to the care planning process. (Completed 04/19/2007 and 04/20/2007) An attendance sheet is available in the clinic as evidence of the in-service.

The Clinic Manager will review the care plan tracking process with the Facility Assistant who is responsible for tracking and scheduling of care plans by 04/19/2007.

There will a 100% chart audit conducted in the facility and will be completed by June 30, 2007:

33% of the records (40) to be reviewed by 4/30/07
33% of the records (40) to be reviewed by 5/30/07
33% of the records (40) to be reviewed by 6/30/07

The Clinic Manager will ensure any deficiencies found in the chart audit data related to the care planning process are corrected and an action plan will be put in place.

The Clinic Manager or Designee will confirm monthly times three months that the care plan tracking process in place has accurately identified all patients requiring either an initial or updated long term care plan has been completed. Findings will be documented on a monitoring tool and will be discussed in the monthly QAI meeting minutes.

Results of the monitoring will be reported to the Area Manager at least quarterly.

The Area Manager will report the status of the facility plan of correction to the Governing Board.


Short term care plans have been completed for the identified patients in the SOD.

The Facility Manager will review the care plan tracking process with the Facility Assistant who is responsible for tracking and scheduling of care plans by 04/30/2007.

The Clinic Manager or Designee will confirm monthly times three months that the care plan tracking process in place has accurately identified all patients requiring either an initial or updated short term care plan has been completed. Findings will be documented on a monitoring tool and will be discussed in the monthly CQI meeting minutes.

Results of the monitoring will be reported to the Area Manager at least quarterly.

The Area Manager will report the status of the facility plan of correction to the Governing Board


Back to Survey Tag Summary for:FRESENIUS MEDICAL CARE DENVER CENTRAL DIALYSIS

Colorado Department of Public Health and Environment
Health Facilities and Emergency Medical Services Division
4300 Cherry Creek Drive South
Denver CO 80246-1530
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